Radiology Coding Alert

You may be losing $$$ if you're writing off subsequent ultrasounds

If you provide more than one obstetric ultrasound per obstetric patient - even during the same visit - make sure you report both ultrasound charges. Otherwise, you could be undercutting your practice's bottom line.
 
Ob-gyns often order obstetric ultrasounds (for example, 76801, Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [<14 weeks 0 days], transabdominal approach; single or first gestation) to show viability, the number of fetuses, fetal position, amniotic fluid volume, fetal measurements, placental location, and fetal weight estimation.

Detailed View? Report 76811

Radiologists also perform these ultrasounds to offer the patient's physician a precise delivery date or to check viability when the patient may have a threatened miscarriage or has a history of habitual miscarriages.
 
Details count: For a more detailed fetal view using ultrasound, you should report 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) or +76812 (... each additional gestation [list separately in addition to code for primary procedure]), says Randall Karpf, owner of East Billing in East Hartford, Conn. Such in-depth ultrasounds allow the radiologist to take more detailed measurements and assess any malformations.

Multiple Ultrasounds May Mean Multiple Codes

Suppose a 35-year-old patient presents at 18 weeks of gestation for a routine ultrasound (76805), but the ultrasound indicates a possible fetal anomaly. The radiologist calls the ob-gyn, who decides to perform an amniocentesis (59000, Amniocentesis; diagnostic) with ultrasonic guidance (76946, Ultrasonic guidance for amniocentesis, imaging supervision and interpretation) during the same visit.
 
The radiologist performs ultrasonic guidance so the ob-gyn can visualize needle placement as he extracts the amniotic fluid sample from the pregnant uterus while avoiding needle contact with the fetus.
 
If the radiologist performs the ultrasound and ultrasonic guidance for the amniocentesis in an independent diagnostic testing facility or private office, he should report both 76805 and 76946-51 (Multiple procedures). In the hospital setting, the radiologist should also append modifier -26 (Professional component) to both CPT Codes .

Modifier -51 May Be Warranted

Even though the ultrasonic guidance is a different procedure from the regular ultrasound, you should append modifier -51 to 76946 because it is the same "type" of procedure and many carriers use the multiple-procedure rules when verifying payment, Karpf says.
 
If the doctor performs the regular ultrasound on a different day than the ultrasonic guidance, then you should not append modifier -51 to your claim. Check with your payer before you append modifier -51, because not all insurers require it.
 
Don't forget: If you report ultrasonic guidance and a fetal ultrasound on the same date, your radiologist should include separate reports in the medical record docu-menting the individual procedures. In addition, the physician should document the specific circumstances that led to the two separate services on the same date of service.
 
"You must have the correct documentation in place," Karpf says. "There is a good chance you'll get paid on appeal, but the easiest way to win an appeal is to prove that the radiologist performed both the guidance and the regular ultrasound, so documentation for both can
be vital."

High-Risk Pregnancies May Warrant Multiple U/S's

Patients with high-risk pregnancies frequently require multiple ultrasounds to assess the fetus' development. Because many insurers will only reimburse one ultrasound per pregnancy, you should submit a letter of medical necessity with your claims for subsequent ultrasounds.
 
And, you may face denials for multiple ultrasounds when the patient has a history of complications with previous pregnancies (for example, 646.33, Habitual aborter; antepartum condition or complication) but is now having an uncomplicated pregnancy. To avoid this problem, be sure to include the patient's history on the claim form using an appropriate "V" code if applicable. Otherwise, insurers will probably view such cases as multiple ultrasounds for an uncomplicated pregnancy and may deny the service.

Pelvic U/S Reveals Pregnancy Dx? Report 76856

Suppose your radiologist performs a pelvic ultrasound on a patient with pelvic pain. The radiologist discovers during the ultrasound that the patient is pregnant. Should you report the pelvic ultrasound code (76856, Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) or an obstetric ultrasound code?
 
Coding solution: "CPT Assistant advises coders to report the pelvic ultrasound per the reason the exam is ordered," says Beth Lawrence, coder at the office of Thomas Randall, MD, in Detroit. If the patient presents with pelvic pain but no suggestion of pregnancy, you should report 76856. If the patient presents as being pregnant (confirmed with a positive pregnancy test), it is an ob ultrasound, regardless of findings.